Although aging is inevitable, the proportion of the population entering ‘old age’ has never been greater. As the boomers start turning 65 this year, this demographic imperative will continue well into the future, doubling in the next two decades.
While it is proper to recognize that aging is a triumph, rather than a disease, we need to also acknowledge that the aging of our society will place unprecedented pressure on Canada’s health care system.
The growing numbers of older adults are driving health costs in Canada. Older adults also use more expensive types of health services, particularly in the acute care setting. Indeed, while people aged 65 and older account for 14.4 per cent of the population they consume nearly half of our public spending on healthcare.
However, what complicates things further is the well-documented but underappreciated heterogeneity of the older population and the impact that this has on health care use. For example, in examining hospitalization patterns among the elderly, a number of longitudinal studies have consistently demonstrated that only a small proportion of older adults are actually high users of hospital services.
Currently, provincial governments are faced with managing resources in the face of an economic downturn. This puts pressures on health system administrators at the regional and provincial levels to consolidate services with the explicit agenda of reducing health care costs.
In such an atmosphere, the opportunity for innovation in health service delivery becomes limited to simply ‘doing the same with less’. With annual per capita growth rates in acute care costs increasing the fastest for older adults and given that this growth rate is expected to continually increase, it is imperative that we increasingly focus our efforts around developing new cost-effective models that are also able to meet the complex needs of older patients.
Our main problem is that while the patients have changed, our systems have not. Our current hospital care model was developed decades ago when the average age of Canadian was 27 years of age and most adults tended to not live past 65 or be living with chronic illnesses, and usually only had one active problem that brought them to hospital.
While things still function well for younger patients like this, it is increasingly being recognized that our current model that focuses on treating one issue at a time often disadvantages older adults who often present with many active chronic health problems.
As our current system’s greatest users, we are increasingly coming to understand how our traditional models of care also put many older patients particularly at risk for adverse complications such as falls, delirium, drug-interactions, functional decline, and death.
What is most concerning is that few have come to appreciate that much of these adverse outcomes are preventable. Studies have demonstrated how the implementation of focused models of care that consider the unique needs of older patients can improve overall care outcomes while at the same time reducing lengths of stay, admissions, readmissions, and inappropriate resource utilization – thereby improving the overall capacity and efficiency of the system.
However, implementing innovative models of care that challenge deeply ingrained traditional ways of providing care has proved to be a significant challenge. Nevertheless, more than at any other point in the history of Canada has there ever been such an urgent imperative, with significant social and economic implications, that will require us to develop comprehensive evidence-based care strategies to improve the care of older adults in need of acute care. Acknowledging the need for reforms in community-based care, older adults will still require hospitalization even under the best of circumstances.In response to the challenge of addressing the complexities of caring for older adults in acute care settings and across the continuum of care, Mount Sinai Hospital in Toronto embarked on a different approach to develop an innovative and comprehensive Acute Care for Elders (ACE) Strategy that puts the needs of older patients and their families first.
As the first major acute care academic health sciences centre in Canada to make geriatrics a core strategic priority, Mount Sinai, implemented a series of evidence-informed but tailored interventions and linked them to create a more seamless, integrated delivery-model spanning the continuum of care. This strategy is further enabled by an interprofessional, team-based approach to care as well as technological innovations with a focus on maintaining the independence of older adults in our community for as long as possible.
While this may sound logical and obvious, despite the fact that the 14.4 per cent of our population that is 65 years and older accounts for 58 per cent of inpatient bed days, few hospitals across the country have made their needs a core strategic priority.
It’s a smart move given that 60 per cent of current hospital expenditures are directed to the older population, and that even small improvements in the way we care for them can have important health, social and economic benefits.
Indeed, since launching our strategy three years ago, Mount Sinai has seen a 31 per cent increase in the number of admitted older adults it serves on an annual basis. In that time, our strategy has allowed us to reduce our average total length of stay per patient by more than 28 per cent, our average ALC days by 18 per cent, and our readmissions by 13 per cent which has allowed us to reduce our overall beds in operation by 5 per cent.
Our patients are now more likely to go directly home, and are more satisfied with our care. Despite the increase in patient volumes, our approach which required minimal financial investments, but rather a different approach to the way we work, has also reduced our direct costs of care per patient by 31 per cent and our overall care costs by more than $6.26 million in 2012/13 alone.
While these results are exemplary, and have positioned our hospital as a national leader in elder care, our ability to do it with minimal financial investments should give other hospitals across Canada that ability to deliver similar results too.
Could the elderly bankrupt Canada?
However, by viewing our current challenges as opportunities to transform our dated models of caring for older adults, we can help ensure that the greater efficiency and capacity that will be needed can be sustained within the existing public system and financing structures to meet current and future demands for hospital care by all Canadians.